Provider Demographics
NPI:1063950061
Name:KALLAL, MEAGAN
Entity type:Individual
Prefix:
First Name:MEAGAN
Middle Name:
Last Name:KALLAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SAINT ANTHONYS WAY
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4568
Mailing Address - Country:US
Mailing Address - Phone:618-463-5171
Mailing Address - Fax:
Practice Address - Street 1:1 SAINT ANTHONYS WAY
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4568
Practice Address - Country:US
Practice Address - Phone:618-463-5171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.008611225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist